Failure to Monitor and Intervene for Bowel Movements, Oxygen Saturation, and Skin Integrity
Penalty
Summary
The facility failed to provide appropriate treatment and care according to provider orders and resident needs for several residents. For one resident with multiple diagnoses including COPD, heart failure, and dementia, the facility did not track bowel movements or provide interventions when bowel movements were not recorded for several days, despite orders for bowel management and the resident's report of chronic constipation. Additionally, the care plan did not address oxygen or bowel management, and there was a lack of documentation regarding oxygen administration, including whether oxygen was used and at what liter flow, even though there was an order to monitor daily oxygen saturation and adjust oxygen to maintain saturation above 90%. Another resident with severe cognitive impairment and Parkinson's disease had provider orders for prune juice and PRN MiraLAX if no bowel movement occurred in 48 hours. However, bowel movements were infrequently recorded, and the medication administration records did not show that MiraLAX was administered as ordered, despite daily sign-offs indicating monitoring. Family members also reported ongoing issues with constipation for this resident, and staff interviews confirmed the expectation for bowel movement tracking and intervention, which was not consistently met. A third resident with livedoid vasculitis and moderate cognitive impairment had an order for weekly skin checks to be documented in the electronic health record. However, there was no evidence of completed skin assessments in the resident's record, despite facility policy and staff statements that weekly skin checks were expected. The resident was also known to refuse baths, which may have impacted the completion of skin checks, but the required documentation and monitoring were not present.